Montana is one of the last five states to continue to use the antiquated fee-for-service Medicaid reimbursement model for behavioral health care – both mental health treatment and substance use disorder treatment. Most states have moved to some type of value-based system where the full cost of care is covered.
Seventy percent of the mental health issues can be treated by your primary care provider. When you see your primary care provider (physician, nurse practitioner, PA), they can treat you for most common mental health issues, such as mild to moderate depression, and refer your for counseling, which your private insurance will pay for.
The other thirty percent of patients are children with a Serious Emotional Disturbances (SED) or adults with a Serious Mental Illness (SMI) diagnosis. These patients need more intensive care, similar to a medical patient who requires a specialist when the primary care doctor can no longer manage their disease.
This thirty percent of children and adults are who the CCBHC model is for. These patients are primarily covered by Medicaid. In Montana, behavioral health providers are reimbursed only for the direct care they give a client, i.e., fee-for-service.
An easy way to understand this is that if you go to your primary care provider, they are reimbursed in a bundle payment called Prospective Payment System (PPS). They will receive a larger payment that will cover the primary care provider’s time (e.g., $200 for a 15-minute appointment), the receptionist who scheduled the appointment, the nurse who takes your blood, the care coordinator who schedules your other referral appointments, etc. The PPS reimbursement covers the full cost of delivering care.
If you see a behavioral health specialist, they will receive only a payment for the time of your visit, i.e., a 50-minute appointment will be paid $94.50 by Medicaid to the therapist. This does not cover any of the other costs of care as it does in medical care.
The CCBHC model will reimburse the behavioral health system similar to the way the medical system is reimbursed. This will cover the full cost of care for the SMI adults and SED children. Currently, the Governor’s Provider Rate Study has shown that behavioral health providers are reimbursed at less than 80% of the cost of delivering the care in the fee-for-service model. This is why funding the full cost of care recommended by the Governor’s Provider Rate Study is so important.
Until we move from a fee-for-service system to a value-based reimbursement that covers the full cost of care and requires outcome tracking to ensure effective treatment, Montana will continue to be at the top for suicide rates, children in foster care, children sent out of state, a collapsing Montana State Hospital, and other issues created by not having a comprehensive community-based mental health and substance use disorder treatment system.
If you have any questions, please contact Mary Windecker, Executive Director, Behavioral Health Alliance of Montana at [email protected] or 406-546-4793.